Antibiotic Stewardship Takes a Village: Role of NursingTeresa Fox, MT(ASCP), BS, M.Ed. CICQuality Improvement AdvisorJuly 20, 2019Alabama Infectious Diseases Society (ALIDS)

Objectives

2

• Define the term “antibiotic resistance”• Define the term “antibiotic stewardship”• Describe action steps that one can take to prevent antibiotic

resistance and the spread of antibiotic-resistant organisms

What are Antimicrobials?

3

• Antimicrobials are a large group of medications that include:• Antibiotics –to treat bacterial infections• Antivirals –to treat viral infections• Antifungals –to treat fungal infections• Anti-parasitics–to treat infections caused by parasites

https://www.medicinenet.com/script/main/art.asp?articlekey=10204

Antibiotics –to treat bacterial infections

Molly is sick.

4

Kelly believes that Molly has a bad cold. Concerned that her daughter’s symptoms might get worse, Kelly takes Molly to an urgent care clinic. She hopes the doctor will give Molly a prescription for antibiotics because she believes that will help Molly feel better fast.

Is Kelly correct that antibiotics will treat her daughter's bad cold?

Molly is sick.

5

Kelly talks with the urgent care doctor about Molly’s cold symptoms. She explains that Molly is very uncomfortable at night when she tries to sleep. Kelly tells Dr. Smith that her neighbor’s child was sick with a cold and was given antibiotics.

Should Kelly expect Dr. Smith to treat Molly with antibiotics?

Antibiotic Resistance Affects Everyone

6

• Antibiotic resistance threatens the use of antibiotics for people of all ages

• Antibiotics are essential treatment for some infections, but also can produce harmful side effects• Upset stomach• Rashes• Interactions with other medications• Diarrhea (e.g., C. difficile)

• 1 out 5 visits to EDs are related to adverse events to antibiotics• # 1 for ED visits for children < 18 years of age

• Antibiotic resistance increases follow-up doctor visits, more lengthy recovery times and costly and toxic alternatives

https://www.americannursetoday.com/antibiotic-stewardship-staff-nurses/

Molly is sick.

7

Dr. Smith diagnosed Molly with a cold, so he did not prescribe antibiotics. Frustrated that Dr. Smith won’t prescribe antibiotics, Kelly remembers that Molly has some leftover antibiotics from the last time she was sick. She decides to go home and starts giving Molly the leftover antibiotics.

Is it safe for Kelly to give Molly leftover antibiotics?

What is antibiotic-resistant bacteria?

8

• Antibiotic resistant occurs when bacteria no longer respond to drugs designed to kill them.

• Anytime antibiotics are used, they can cause antibiotic resistance• The bacteria is no longer killed by the

drug and the bacteria continues multiply

• Some resistant bacteria can be harder to treat and can spread to other people

• Broad spectrum antibiotics do not only kill bad bacteria

Viruses that attack bacteria, called phages, have a big head that contains genetic material and tail fibersthat affix to a specific strain of bacteria. Genetic material, injected into the bacterium, hijacks itscellular machinery to produce more copies of the virus.

KATERYNA KON/SCIENCE PHOTO LIBRARY

9 https://www.pinterest.com/camdenclarkmc/

Antibiotic Prescribing in U.S. Hospitals

10

• Half of hospitalized patients receive at least one antibiotic and up to 50% of these patients, antibiotics are unnecessary or inappropriate.

• Misuse contributes not only to adverse drug reactions, like C. difficile, but to the emergence of other MDRO.

• C. difficile infections (CDI) are a major problem; most common cause of healthcare associated infections in US.

• CDI annual expenditure exceeds $4.8 B in hospitals alone• All settings CDI

• Half million infections annually• 83,000 at least one recurrence• 29,000 will die within 30 days of initial diagnosis

11

12

Multidrug-Resistant Organisms- MDROs

13

14

• January, 2019- Columbia University’s Irving Medical Center, NYC isolated unusual strain of E. coli

• E. coli, a common gut bacterium• With ineffective treatment, half patients

would die • As resistance increases, some patients last

hope is colistin• Columbia E. coli had a mutation in a gene,

MCR-1, making the organism resistance to colistin

May 15, 2019

AL Among the Highest Rates of Antibiotics

15

16

Managing Super Bugs

17

• Quickly identifying and responding to potential outbreaks with extra precautions and targeted antibiotics to slow or prevent outbreaks

• Focusing on containing resistant bugs in healthcare settings and community

• Use antibiotics appropriately to slow or prevent the development of new resistant strains

Over-the-counter drugs in Bangkok. Yvan Cohen/LightRocket/Getty

18

Antibiotic Stewardship

“coordinated interventions designed to improve and measure the appropriate use of agents by promoting the selection of optimal drug regimen, including dosing, duration of therapy, and route of administration”Infectious Diseases Society of AmericaSociety of Healthcare Epidemiology of AmericaPediatric Infectious Diseases Society

What is Antibiotic Stewardship Program (ASP)?

19

• CDC report states improving antibiotic use is one of the most important needs in reducing antibiotic resistance.

• Antibiotic stewardship is the effort to:• Measure antibiotic prescribing• Improve antibiotic prescribing so that antibiotics are only

prescribed and used when needed • Minimize misdiagnoses or delayed diagnoses leading to underuse

of antibiotics• Ensure that the right drug, dose, and duration are selected when an

antibiotic is needed

It’s about patient safety and delivering high-quality healthcare.

20

MITIGATE Antimicrobial Stewardship Toolkit

https://qioprogram.org/sites/default/files/editors/141/MITIGATE_TOOLKIT_final_approved%281%29_508.pdf

Core Elements of Acute Care & LTCF

21

Knowledge Gap: Challenges for Bedside Nurses

22

1. Unfamiliar with the concept of antibiotic stewardship2. Lack of knowledge of microbiology and antibiotic use3. Belief that antimicrobial stewardship is not a nursing function4. No method to measure the impact of nursing participation in

stewardship efforts

Role of Nurse Executive in ASP

23

• Central role in spearheading strategic nursing engagement in Antibiotic Stewardship Programs (ASP)

• Demonstrate the value of bedside nursing being fully engaged in ASP• The Joint Commission requires nursing involvement in ASP• CMS and Medicaid Services has proposed making ASP a Condition of

Participation for acute care hospitals• Identify as a key component of Patient Safety• Highlight the benefits of good ASP on nursing workload (i.e. better IV-

to-PO conversion will reduce medication administration time)• Ensure annual antibiogram is created and distributed to all clinicians • Add measures related to antibiotic use, like C. difficile infections to

Magnet Recognition Program

Nursing and ASP Functions Overlap

24The Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There, by Olans, Olans, and DeMaria

Nursing and ASP Functions Overlap

25

What is the role of bedside nursing?

26

• Obtain appropriate cultures, using proper technique, prior to administration of antibiotics. • Understand laboratory process of culturing

• Use microbiology results to help guide in optimal selection of antibiotic and guide decisions to stop therapy (colonization/infection)

• Ensure practices to ensure good antibiotic use is included in other quality improvement efforts

• Ensure a detailed allergy history---including patients and families about an accurate antibiotic allergy history

• Help inform decisions to start antibiotics promptly when bacterial infection is suspected (sepsis) • Use Minimum Criteria for prescribing when available

https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/antibiotic-tool.html

27

What is the role of bedside nursing?

28

• Participate in and actively prompt discussions about antimicrobial usage: • Upon receiving laboratory results, notify the prescriber and

facilitate an “antibiotic time-out” (re-assessment of the antibiotic prescribed).• If culture results are negative:

• Recommend discontinuation of antibiotics• If culture results are positive:

• Provide susceptibility report to encourage use of a narrower spectrum antibiotic, if available

• Assess for de-escalation opportunities (e.g., from IV to P.O.)

What is needed by bedside nursing to meet the role?

29

• ASP education to bedside nurses.• Microbiology education and training on how to obtain cultures and

interpret results• Education about infection versus colonization• Assertiveness training to engage in discussion with team• Information on IV-PO switch criteria• Training on taking an allergy history• Encourage nurse champions at the unit level• Include bedside nurses in stewardship rounds• Education and messaging for nurses as part of efforts to raise

awareness about usage and resistance

30

Nurse

ID

Administration

Pharmacy

MicrobiologyInfection

Prevention and Control

Case Management

Hospital

Patient and

Family

Workflow Communication

How to Design a Successful ASP

31

• Ingredients for successful stewardship include:• Education for nurses and providers

• Evidence-based guidelines for clinical assessment, testing for and treating infections

• Use antibiotics only when clinically indicated• Accurate assessment of changes in condition• Accurate, timely communication and documentation of

signs/symptoms and laboratory results• Assist patients in managing symptoms of non-bacterial infections

Symptom Relief / Delayed Prescribing

32

Molly is still sick.

33

Molly is still sick after a few days. Kelly decides to visit Molly’s pediatrician, Dr. Jones, to get a second opinion. Dr. Jones explains that antibiotics save lives – and when a patient needs antibiotics, the benefits outweigh the risks of side effects or antibiotic resistance. But when antibiotics aren’t needed, they won’t help and could still hurt Molly.

Should Kelly be concerned about the side effects from antibiotics?

Molly is still sick.

34

The reason Kelly had leftover antibiotics is because the last time Molly was sick, Kelly stopped giving her the antibiotics when she started feeling better.

Should Kelly have given the antibiotics to her daughter exactly as prescribed by the doctor?

Everyone’s Role in Stewardship

35

• Use antibiotics only when clinically indicated; Avoid asking your provider for antibiotics

• Practice excellent hand hygiene • Follow recommended infection prevention and control practices• Use antibiotics only as prescribed by your doctor including taking

the full prescription• Never take leftover antibiotics for a later illness. • Never take antibiotics prescribed for another person• Stay home from work when you’re sick• Get a flu shot every year• Cover your cough or sneeze with a tissue or use your sleeve (near the

shoulder or elbow)

https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720

Chilling Predictions

36

“In such a case the thoughtless person playing with penicillin treatment is morally responsible for the death of the man whofinally succumbs to infection with the penicillin-resistant organism. I hope the evil can be averted.”

Alexander Fleming;1945 New York Times

“If we are not careful, we will soon be in a post-antibiotic era”

Dr. Thomas Frieden, past Director of CDC; 2013

Slowing Super Bugs

37

• Does Nature hold the key to the next great bacteria-killer?

Checklist for Outpatient ASP

38

39

https://www.ahrq.gov/nhguide/index.html

Checklist for Core Elements of Hospital Antibiotic Stewardship Programs

40

41

State Efforts to Improve Antibiotic Use

42

Why we selected URIs to track?

43

• Upper Respiratory tract infections (URIs)• Common cold, laryngitis, pharyngitis/tonsillitis, acute

rhinitis, acute rhinosinusitis and acute otitis media. • Lower respiratory tract infections (LRTIs)

• Acute bronchitis, bronchiolitis, pneumonia and trachealis. • 1/4 population will visit their GP because of a RTI each year • 60% of all antibiotic prescribing in general practice is for RTIs• At least 30% of these antibiotics are unnecessary• 10% decrease in inappropriate prescribing in the community

can result in a 17% reduction in Clostridium difficile infection

QIN-QIO Efforts

44

• Total Recruitment- 108 ED, Pharmacies, and Physician Practices• Implement CDC Four Elements of Outpatient Antibiotic Stewardship

to reduce inappropriate antibiotic use:• Reduce C. difficile • Slow development of bacteria resistance• Preserve antibiotics for future treatment

• Successfully implemented all four elements in 87% of recruited facilities/practices

• Compared May-June 2017 to May-June 2018• RIR- 4.92 Recruited Practices• RIR- 1.05 Non-recruited Practices

Recruited Facilities by Community Coalitions

45

Antibiotics Prescribing for URIs

46

Cephalosporins Prescribing Rate

47

Fluoroquinolones Prescribing Rate

48

Do ASP Activities Work?

49

Overall Antibiotic Use

Do ASP Activities Work?

50

Interventions

Cephalosporins

Does AS Activities Work?

51

Fluoroquinolones

Does ASP Activities Work?

52

ESBL

Do AS Activities Work?

53

Rocephin Injections

Do ASP Activities Work?

54

Rocephin and ABX

Free CDC Educational Materials

55 https://www.cdc.gov/antibiotic-use/community/materials-references/print-materials/adults/index.html

Thank youQuestions

56

Resources

57

Redefining the Antibiotic Stewardship Team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurse in Hospital Antibiotic Stewardship Practices, White paper, 2017’Strengthening nurses’ role in antibiotic stewardship

C:\Users\la2302\Desktop\Strengthening nurses’ role in antibiotic stewardship.mhtAntibiotic Use in Long-Term-Care Facilities (SHEA position paper)

https://www.shea-online.org/images/guidelines/Abx-LTCF96.PDFAlliance for the Prudent Use of Antibiotics

www.tufts.edu/med/apua/CDC Campaign to Prevent Antibiotic Resistance

https://www.cdc.gov/antibiotic-use/week/index.htmlCore Elements of Antibiotic Stewardship for Nursing Homes- CDC

https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlhttps://www.cdc.gov/longtermcare/prevention/index.html

National Nursing Home Quality Improvement C. difficile Infection Prevention Assessment Checklists

https://www.nhqualitycampaign.org/files/AntibioticStewardship_Assessment.pdf

Resources

58

Field Guide to Antibiotic Stewardship in Outpatient Settings http://atomalliance.org/download/field-guide-to-antibiotic-stewardship/

Nursing Home Antimicrobial Stewardship Guide; https://www.ahrq.gov/nhguide/index.html

Nurses in Long-term Care Facilities: Antibiotic Use and Antibiotic Resistance http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/hcp/asp/ltc/modslidenurseabx.pd

`CDC- Antibiotic Prescribing and Use in Doctor’s Office https://www.cdc.gov/antibiotic-use/community/materials-references/print-materials/adults/index.html :

BE AN ANTIBIOTICS WHIZhttps://www.cdc.gov/antibiotic-use/community/about/quiz.htmlhttps://www.newsweek.com/2019/05/31/death-antibiotics-running-out-effective-drugs-fight-superbug-army-1423712.html

This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 18.SS.AL.C3.01.10.001

Resources

59

The Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There ? Clinical Infectious Diseases, Volume 62, Issue 1, 1 January 2016, Pages 84–89, https://doi.org/10.1093/cid/civ697 Published: 11 August 2015 C:\Users\la2302\Desktop\Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There Clinical Infectious Diseases Oxford Academic.htm